Building a Community of Medical Learning - A Century of Case Records of the Massachusetts General Hospital in the Journal.

As much as they represent an invaluable window into the history of medicine more generally, the Case Records also reflect a self-conscious effort to alter and guide medical practice by building an active community, both local and global, centered on consideration of carefully selected and curated cases. These efforts have seen both continuity and change over the tenures of six different Case Records editors. Throughout, the Case Records have linked the local medical communities of MGH and Boston with a global audience. Responding to requests from physicians unable to attend case discussions at MGH, including former MGH house officers who, having migrated west to Los Angeles and San Francisco, “missed the stimulus of their hospital connection here, and wanted to keep in touch,” as well as “a number of physicians in Europe, Asia, and Australia,” the Case Records were, in Cabot’s words, an attempt to share “the standards of this hospital, its standard of record system, of physical examination, of pathological examination after death, and of diagnostic reasoning […] outside our walls.” 35 , 2 , 36 Six years into their publication in the Journal , in words that resonate today, the Journal ’s editors reflected on the Case Records’ role in teaching clinicians “to think — the highest achievement of all teaching, and especially needed in a time when the tendency in medicine increasingly is toward dependence upon technic rather than upon observation and reasoning.” 37 This ambition to engender “reasoning power and professional good feeling” quickly took on global proportions, as the cases reached six continents within 4 years after their inception. 37 , 36 Subsequent Case Records editors continued to spread the Case Records widely, with Benjamin Castleman obtaining a grant from the Rockefeller Foundation to share them with all nine U.S. military commands during World War II. 4 Their global reach continues today. 38 , 39 Successive Case Records editors furthered many of their predecessors’ goals, while reshaping the Case Records in response to both shifts in medicine and feedback from their expanding audience. The 400-plus letters to the editor and articles the Journal has published about the Case Records — whether they considered the cases individually or (less commonly) collectively as pedagogy — make for fascinating reading. A group of clinicians in the 1920s regarded the Case Records as a “system of teaching … unique in American medicine, probably in world medicine.” 37 A New Hampshire clinician enthused that “Dr. Cabot, with his fund of knowledge and with his keen nose for a diagnostic scent … unravels the knots after the manner of the best writers of detective fiction,” while another reader wrote that “for nine evenings each winter since 1921, we have figuratively speaking, transported Dr. Richard C. Cabot and his colleagues from the Massachusetts General Hospital, Boston, to Prescott, Arizona, at no greater cost than a subscription.” 40 , 37 Other early readers suggested ways of organizing group discussions of cases, while starting a tradition of adding or correcting differential diagnoses and reasoning. 41 Over the course of the 20th century, readers’ feedback ranged from corrections of typos or minutiae such as Robert Frost’s birthplace (San Francisco, not New England — an error deemed “a serious step lightly taken”) to more substantive recommendations for changes such as including discussions of the costs of care in each case or adequately documenting patients’ occupational histories. 42 , 43 , 44 , 45 , 46 Perhaps revealing an enduring (if playful) bicoastal rivalry, a group of readers from San Francisco considered whether MGH physicians had “a home-court advantage” in reaching correct diagnoses, conducting a statistical analysis to support their reasoning and prompting a reader from New Haven to ask to see “how the MGH wizards would fare in some away games.” 47 , 48 Still others leveled more fundamental critiques concerning the ongoing utility of the Case Records. Such challenges ranged from discussions of the evolving methods and timing of diagnosis (e.g., from postmortem to antemortem findings) to the implications for the Case Records of shifts in clinical communication and reasoning, such as the advent of the “problem-oriented” approach to medical documentation and care introduced by Lawrence Weed in the 1960s. 49 , 50 , 4 Others critiqued the performativity of the CPC, the emphasis on disease over the subjective experience of illness, and the relevance of the Case Records ’ more obscure diagnoses to routine care (although one clinician, relating an actual experience of hearing hoofbeats and seeing escaped zebras from a local carnival, noted that “even in Worcester, Massachusetts, when one hears hoofbeats one may occasionally see zebras”). 51 , 52 , 53 , 54 , 55 And while the editors of the Case Records and the Journal could point to enduring reader interest as further support for their utility, they made (and recognized) changes throughout the century. In the first half of the 20th century, for example, they expanded the pool of discussants to include specialists (reflecting rising specialization in medicine). By the late 20th century, they acknowledged that discussants increasingly relied on antemortem findings to render their diagnoses. 2 , 4 They started giving more space to care management (ranging from the use of emerging pharmaceuticals and surgeries to palliative care). 56 And in recent years, they have begun sharing patients’ perspectives on their own cases. 57 , 58

The Case Records have promoted various forms of presumed diagnostic excellence and reasoning, as experts have brought the existing medical literature to bear on their differential diagnoses and justifications for their choices. At the same time, one of the enduring lessons, both intentional and otherwise, of the Case Records has been the need for diagnostic and therapeutic humility. As a Journal editorial noted months before its first Case Record appeared, “If for nothing else, these Case Records are of exceptional value because of their honest acknowledgement of mistakes.” 40 The very structure of the Case Records, in which discussants often do not know the final diagnosis but must reason through the information available to them, has led many esteemed physicians to be humbled by the limitations of their own and the wider profession’s knowledge. Cabot found himself in such circumstances on more than one occasion. 5 , 4 In a 1929 case of a patient presenting with “vertical headache,” for example, a student asked, “Is primary carcinoma of the lung ruled out here?,” suggesting that the headache was due to metastatic spread. 59 “We have not a bit of positive evidence of that,” Cabot responded, only to be humbled by the diagnosis affirming the student’s suspicion. He then reflected, “That diagnosis of lung cancer was a very good diagnosis. I never should have made it.” In 1951, the prominent surgeon and frequent Case Records participant Edward D. Churchill bristled at being pushed to make an incorrect guess on the basis of a shadow on an x-ray, leading an editorialist to comment that “to see the top brass thrown to the lions while the spectators watch hopefully for blood is not without its rewarding features.” 60 , 61 Speaking to the enduring appeal of candor in clinicopathological exercises modeled after the Case Records throughout the United States, Alan Gregg, the director for medical sciences at the Rockefeller Foundation, observed that “the clinico-pathological conference is the wonder and admiration of many of our foreign visitors, who see in it a candor and fearlessness altogether to the credit of American Medicine.” 2 In the ensuing years, the Case Records less often included verbatim discussion comments, but admissions of personal and collective limitations continued to offer a rich source for the production and evaluation of knowledge. In one case, a presenter who had performed a carpal-tunnel–release surgery on the wrong site openly discussed his mistake in “hopes of stimulating discussion and encouraging the development and following of procedures that would minimize the risk for such events in the future.” 62 And in a case involving erythrocytosis, perinephric fluid, and renal failure, a puzzled physician noted that “the patient and his doctors are very interested in any insights from physicians who may have seen similar cases or could provide suggestions for further workup or management of this seemingly unique problem”; this appeal led to a collaboration with readers that resulted in the identification of a new syndrome, TEMPI (an acronym for telangiectasias, elevated erythropoietin and erythrocytosis, monoclonal gammopathy, perinephric fluid, and intrapulmonary shunting). 63 , 5 , 64 This tradition continued amidst the uncertainty of the early months of the SARS-CoV2 pandemic, when physicians reasoned through the advisability of using therapeutics such as hydroxycholoquine that a few short months later were rendered obsolete. 65

Physicians have learned from cases for hundreds of years, but the way they have done so has varied over time and place. The emergence of the Case Records at the Massachusetts General Hospital (MGH) at the start of the 20th century represented a self-conscious effort to instruct the medical profession by means of structured discussion of an individual patient’s disease course. Drawing on the case-based instruction that had been implemented at Harvard Law School and Harvard Medical School, as well as experiments and discussions of its broader utility in medicine in which he had engaged along with figures such as Walter B. Cannon, Richard C. Cabot founded the Case Records in 1915. Having convened MGH physicians and visitors for case discussions beginning in 1910, Cabot sought to share these discussions with a wider audience. 2 Initially published as a stand-alone subscription service, the Case Records moved to the Journal (then known then as the Boston Medical and Surgical Journal ) 8 years later. 3 , 2 , 4 , 5 Each collective deliberation was presented in the sequence in which the case played out, moving from the patient’s presentation through the differential diagnosis to the establishment of a diagnosis. Appearing amidst other pedagogical revolutions, such as the rise of 4-year medical school curricula and hospital-based training, the Case Records were progenitors of a genre of medical instruction that came to be known as the CPC. Capturing several thousand of these deliberations, the Case Records offer a rich repository of insights into the art and science of medicine in the United States.

Over the past 100 years, the Case Records have trained generations of physicians by creating a dynamic local and global community committed to learning from actual cases. As the Case Records enter their second century, they continue to offer a touchstone of rigorous clinical reasoning for both enduring and new purposes, from training clinicians around the world to serving as a diagnostic gold standard for emerging AI systems. 66 The vast repository of clinical details in the archives will undoubtedly yield further riches as it’s explored more deeply. Thus, Cabot’s vision of the Case Records as a means of spreading “the benefits of some of the knowledge gained in our hospital […] to cities and countries very far from our gates” continues to be realized. 36